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We sit down with Michael J. Grace, attorney and author of The Mumbo Jumbo Fix: A Survival Guide for Effective Doctor-Patient-Nurse Communication. We explore how health care communication has evolved before, during, and after COVID. From the rapid rise of telemedicine to the increasing role of nurse practitioners and physician assistants, we discuss the challenges these shifts bring for both providers and patients. Michael shares insights on reducing medical errors, empowering patients to be better communicators, and how to improve doctor-patient-nurse interactions in today’s complex health care landscape.
Michael J. Grace is an attorney and author of The Mumbo Jumbo Fix: A Survival Guide for Effective Doctor-Patient-Nurse Communication.
He discusses the KevinMD article, “Health care communication in a post-COVID world: What’s changed and what’s not since the pandemic.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Michael Grace. We’re going to talk about his article, Health Care Communication in a Post-COVID World: What’s Changed and What’s Not Since the Pandemic. That’s an excerpt from his book titled The Mumbo Jumbo Fix: A Survival Guide for Effective Doctor, Patient, and Nurse Communication.
Kevin Pho: So you’re an attorney and you wrote this book. We’re going to talk about this article a little bit, but just tell us about the events that led you to write this book in the first place.
Michael Grace: Sure. I’ve always been passionate about communication. I was a trial lawyer for most of my adult life defending health care providers, doctors, hospitals, and nurses. That came to me naturally because I was a communication major as an undergraduate and as a graduate student. Then I developed a second career and became a hospital risk manager and a patient safety officer. For the last seven years, I’ve been teaching nurses at the University of California in a program that I designed, dealing with communication. So, it’s my passion, it’s what I love, and that’s why I wrote the original book, which came out toward the end of COVID in December of 2021.
Kevin Pho: Alright, and an excerpt from the book is titled Health Care Communication in a Post-COVID World: What’s Changed and What’s Not Since the Pandemic. Now, tell us about this excerpt for those who didn’t get a chance to read it.
Michael Grace: Yes, I thought COVID had such an enormous impact on me and everybody I knew, and I knew some of the laws had changed since I had written the first edition. I thought it was time for an update. As I was researching for the second edition, much of what I had experienced myself and thought to be true was confirmed by the research. There are a lot of new things that have happened as a result of COVID and a few things that have not changed.
If I could look at the things that have changed first, telemedicine, of course, existed before COVID. But once the government imposed a lockdown, most people had to find an electronic means to meet with health care providers, often with people they had never previously seen in real life. That carries a lot of challenges, both for the provider, who is typically unschooled in how to do an effective clinical examination with Zoom or on a smartphone, and certainly for the patient. There are also new legal responsibilities for the provider. For example, they’ve got to, at the outset, not only identify themselves but also make clear to the patient that they have a right to traditional medical care, a face-to-face encounter, and all that has to be documented.
One of the chapters in my book is devoted to how one goes about doing that. As part and parcel of the change in telemedicine, the federal government temporarily relaxed the encryption rules—all those HIPAA protections—so you, for example, could use your smartphone and talk to a patient on their smartphone using FaceTime. Now that the pandemic is officially over, the government has reimposed very strict encryption rules on all providers and encourages all patients to make sure that their devices are also secure.
We had what was called an interstate compact before COVID came out a few years before. What that allows is a streamlined process for providers to practice across state lines. That’s made an enormous change. Now we have over 40 states and others whose applications are pending to allow providers to do just that. So, it’s really revolutionizing the way people can see doctors and the geographic area in which doctors practice. So that was one really huge change in telemedicine.
Another big change is the whole use of physician extenders. I don’t know if you and your practice use them, but lots of physicians do. And now that we have such a shortage of physicians, we find these extenders, or nurse practitioners, are taking over primary responsibility for patient care. In some states, like California, it’s now law that nurse practitioners, if they meet certain requirements, no longer need to be supervised by a physician at all. This poses tremendous potential confusion on the part of patients who don’t really know the difference between a doctor of nursing practice and a medical doctor. They don’t understand that this person’s scope of practice by law is limited compared to a physician who has a lot more training and clinical experience to get their licensure.
So that was another big change. I think everyone experienced nurses as being the real heroes of the pandemic. But the pandemic took a real toll. They were leaving the profession before COVID, and since COVID, a rapidly aging nursing population has shrunk. That means that we’ve gone to more foreign nurses and foreign physicians as well.
And that always carries with it the potential of communication problems—both cultural clashes as well as just verbal communication with people whose first language is not necessarily English. I know that the hospital I worked in, even before COVID, would have had to shut down if we had not every year gone to Canada to recruit doctors. And I’m from San Diego, and if we didn’t have Filipino nurses in San Diego health care, we wouldn’t have a health care system. We’re even more reliant on foreign-born nurses and physicians now than ever.
There’s also been a concentration now in health care organizations. There are fewer of them, many communities have lost their hospitals, and more procedures are being done in outpatient settings. Of course, the consequences are prices have gone up, which is maybe a bit counterintuitive. I know it was to me. The hope was that if a bigger organization steps in, they’ve got greater purchasing power and can reduce costs. That hasn’t happened. The costs have gone up, and we’re not getting better quality as a result of that consolidation either. In some areas, results are better than before consolidation, and in other areas of medicine, they’re worse.
Lastly, I would say there have been some big behavioral changes that I had experienced, and the research confirmed that others have as well. Those behavioral changes include a reluctance on the part of people to accept any limitation on their personal freedoms. I think we were just sick up to here with lockdowns, and we don’t want people telling us what to do. There’s also a real skepticism of expert opinions, and we see that skepticism of Dr. Fauci, of the Center for Disease Control, and of the World Health Organization.
Lastly, I’ve experienced—and I see it every day, it seems like, on the internet—what I call a coarsening of public discourse. Publicly and privately, there’s just more rude behavior. You see it on airplanes, people getting kicked off of planes, and people just talking badly to one another. So, all of these things make it harder to communicate effectively with provider-to-patient and patient-to-provider.
Kevin Pho: Let’s talk about the end result of the cumulative effect of all these post-COVID changes in terms of the difficulties and impediments that it places between clinicians and patients. What would you see as the most detrimental effect when it comes to patient care because of the cumulative effect of these post-COVID changes?
Michael Grace: Errors are increasing, they are not decreasing, which is shocking when you think of all the attention and all the money and all the lip service that has been paid to keeping patients safe. The primary root cause is this miscommunication, and I think that’s the most important takeaway. Another takeaway is that patients are still being excluded largely from communication education in the health care field.
We do a good job of teaching them about their disease process and how to stay well, but we don’t do a good job at all of teaching them how to communicate in the baffling world of health care to begin with. We don’t do anything to teach them about their own barriers to understanding what even a clearly spoken physician is telling them. In other words, we’re siloing and excluding them. We also silo physicians and we silo nurses. Doctors write for nurses about health care communication. Nurses typically write for nurses. Nobody is writing for patients.
It’s my firm belief that we are not going to move the needle on decreasing errors related to miscommunication until we get everyone literally on the same page. And I’m happy to say that my book is the first one and the only one in the field that is addressed to both doctors, patients, and nurses. Every single chapter enables each of those three participants to understand the difficulties the other two have, the barriers for their understanding, as well as what needs to be done to cure one’s own impediments, if you will.
Kevin Pho: Now, when it comes to teaching patients, like you said, they don’t have a lot of training in terms of how to communicate in our health care world. What would you teach patients?
Michael Grace: I would cover a lot of basics, and I think of them as guardrails, that if we bring patients into the education process, we can improve a whole host of problems in health care. For example, hand hygiene. One thing we all did learn during COVID was the importance of hand hygiene. Well, long before COVID, every hospital room and every medical facility I was familiar with had gel machines. You gel in and you gel out before and after every patient encounter. I was responsible for a lot of the covert studies that we did in our hospital pre-COVID, and the compliance was woefully inadequate, to be quite candid. And that wasn’t just my hospital—that’s across the whole spectrum.
We got a lot better during COVID, but now we’re backsliding. If you teach patients, they have the right to respectfully say, “Doctor, nurse, I would appreciate it if you would gel in before doing your examination.” Just as a reminder, because all health care providers are busy. They’re always in a rush. If the patient is there to say, “It’s my health if you wouldn’t mind,” they’re not going to get an argument. In fact, it will probably be appreciated.
Another example is the wristbands that we put on every patient at a hospital. We never tell them why those are there and why they are important. As a risk manager, every single week, unfortunately, I examined and investigated cases where the wrong patient was taken by a transporter to the wrong area of the hospital for a procedure that wasn’t ordered for them. Fortunately, most of the time, that error was caught before the actual procedure was done. But not always.
Oftentimes, phlebotomists—who were one of the worst offenders—would rush in, do needle sticks without asking the open-ended question, “What is your name? What is your date of birth?” and compare that information with the medical record order number on the materials that they’re looking at. If patients were educated on why that’s important, they wouldn’t hesitate to say, “Don’t you need to ask me my name? Don’t you need to ask me my date of birth?” with a smile on their face. Again, I’m a big advocate for good communication, but respectful communication, compassionate communication, and common sense communication. And that’s what I’m hoping for.
Most nurses and doctors are trained about handoff communication. And if the patient knew that this is what is expected of their provider and that best practice is for it to occur at their bedside so they can participate and correct any misunderstandings in real time, we would have a lot less miscommunication. But patients are never going to be empowered to do that unless they’re informed why that’s important and that it is standard practice.
One thing that happened between the original publication of my book and this updated second edition that just came out this month is that I was hospitalized myself for 10 days, and I examined that as a case study in one of the chapters. One of the weak links was the failure of hospitalists to do handoff communication one to the other. And in so many institutions, you see a different hospitalist every day as a patient. If they aren’t taking the time to look in the record to find out what happened on the prior shift—and better yet, talk to the off-going hospitalist—all kinds of errors can occur.
I was shocked that this happened so often in my own care. And had I not known how the process was supposed to go and spoken up to say, “No, that isn’t the medication that my surgeon had prescribed,” or, “No, I am not going to be discharged because another hospitalist has ordered a surgical consultation,” all of that was unknown to these people, which is really disheartening, but that’s easily solved. So those are just some examples of how by educating and empowering patients, it’s going to help physicians and nurses be better and keep patients safer. It’s a minimal cost and minimal time to explain these things, and I think the rewards are really significant.
Kevin Pho: So let me ask that question from the clinician standpoint. In this post-COVID world, tell us some of the red flags or warnings clinicians should look out for to maintain optimal communication in the advent of all these changes. What are some things that we need to look out for?
Michael Grace: Well, I think there are several. First is family members. Too often, in my experience, physicians want to ignore the family and only focus on the patients. And certainly, family members can get in the way, but they can also be valuable assets. If the physician first clears with the patient that it’s OK to include the family, you’ve got to make sure that you’re answering all those family members’ questions. Even if you’ve already done the informed consent process with your patient—say you’re scheduling a surgery—now the family comes in, and they have a bunch of questions, and the patient wants them to be there. You do have to take the time to satisfy them, because if anything goes wrong, they are going to blame you, and it’s going to result in litigation.
So, that’s a big red flag that physicians often don’t appreciate—the importance of speaking with the family, not ignoring them. That’s just one of many examples.
Kevin Pho: We’re talking to Michael Grace. He’s the author of The Mumbo Jumbo Fix: A Survival Guide for Effective Doctor, Patient, and Nurse Communication. His excerpt from that book we’re talking about today is Health Care Communication in a Post-COVID World: What’s Changed and What’s Not Since the Pandemic. Michael, let’s end with some of your take-home messages that you want to leave with the KevinMD audience.
Michael Grace: My goal, and it’s my passion, is to get my book in every medical school. It’s already in some, in every nursing school, and in every residency program. It’s already in one program in Arizona. To get my book in the gift shops of hospitals and in front of patient advocates, and it’s gotten a great reception and a five-star Amazon review from physicians, nurses, and patient advocates. Because I want to break down the silos, and I don’t see that anybody else is doing it.
But for all the time and money and years spent talking about this, we haven’t moved the needle. And now, since more is happening in the outpatient clinical setting, we’re doing very little even to assess the harm that is occurring there. In the inpatient settings, we know it’s being underreported. As my article states, there was a compelling 2024 study published in the New England Journal of Medicine that addresses this very issue that we are not moving forward. If anything, we’re moving backward. So, it’s in everyone’s interest to take a new approach, and that’s what I’m offering.
Kevin Pho: Michael, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.
Michael Grace: Thank you very much. Have a good day.
